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rnrvu 0- <br />l.LA7N I Y NAME I <br />SfTE NAME: <br />INSPECTION DATE:?1�C� <br />SRE ADDRESS: <br />CITY/STATE/ZIPCHANGES <br />SRE/OWNER/YES <br />NO <br />TANK TANK TAM( <br />WWPERMIT <br />DD <br />TANK <br />TYPE Of INSPECTION <br />tC7MV"UJTER <br />• D • ?� <br />PEAPER • � <br />IIE)(P-nAFF <br />PER <br />PER• <br />EXP. DATE EXP. DATE EXP. DATE <br />OPERATIONAL TANK <br />MAJ <br />MIL <br />PERtifT TO OPERATE <br />1 <br />2 <br />CHANGE N CONDITIONS TO OPERATE <br />J <br />a <br />APPROVED CONSTRUCTION N <br />6 <br />a <br />WRITTEN MONITORING PROCEDURESN <br />7-7— <br />8APPROVED <br />APPROVED MONITORING SYSTEM E <br />0 <br />10 <br />MONITORING SYSTEM OFERATIarAL–E <br />11 <br />12 <br />APPROVED MONITOR PREOUENCY N <br />iJ <br />14 <br />MONITORING RECORDS MAINTAINED E <br />15 <br />16 <br />ACCESS CASING SECURED N <br />17 <br />19 <br />P1FhNG <br />19 <br />20 <br />INVENTORY RECONCILIATION E <br />21' <br />22 <br />TANK GAUGING E <br />23 <br />24 <br />APPROVED RESPo NSE PLAN N <br />251 <br />28 <br />. <br />UNAUTHORIZED RELEASE OCCURRENCE <br />271 <br />28 <br />SAMPLING <br />lzuw <br />13U <br />APPROVED TAM( REPAIRS <br />31 <br />32 <br />UNAUTHORIZED RELEASES REPORTED <br />37 <br />Ja <br />SAFETY HAZARD <br />35, <br />36 <br />CONDITIONS ABATED <br />J7 <br />TEMPORARY TANK CLOSURE <br />REMOVAL OF RESIDUAL <br />is. <br />J9 <br />FLAMMABLE VAPORS REMOVED <br />a0 <br />ACCESS LOCATIONS SEALED <br />at <br />42 <br />POWER DISCONNECTED <br />aJ <br />OWNER/OPERATOR MONn DRING <br />u. <br />45i <br />PERMANENT TANK CLOSURE <br />REMOVAL OF RESIDUAL MATERIALS <br />a6 <br />47 <br />PIPING <br />a9 <br />FLAMMABLE VAPORS REMOVED <br />50 1 <br />ffiffi <br />UNAUTHORIZED RELEASE <br />511 <br />52 <br />SAMPLING <br />531 <br />54 <br />IMPROPER ABANDONMENT <br />55i <br />56 <br />THE MARKED ITEMS REPRESE,ANTT VIOLATIONS AND MUST BE CORRECTED AS <br />SYSTEM STATUS (MUST ~K ONEI <br />FOLLOWS- -- �Z-m <br />57 MINOR 58 5B <br />v101 ❑ ❑ <br />VIOL VIOL <br />R561 4N LOCAL HEALTH DISIRI <br />NSP: <br />RECEIVED BY: <br />POST OFFICE BOX 2009 <br />2yC <br />STOCKTON. CALIF. 95201 <br />ffTN: ENVIRON. HEALTH <br />TinE: <br />PHONE' <br />RECK <br />rnrvu 0- <br />